Maya Adam:

Welcome to Health Compass. I'm your host, Maya Adam, director of Health Media Innovation at Stanford Medicine.

Bryant Lin:

I've been practicing medicine for basically 20 years, and I've never seen an MRI that said somebody had 50 areas of metastasis in the brain. 50, 5-0, I had that.

Maya Adam:

Today's episode is a story of resilience and a powerful case study on how to leave a legacy. It stems from the life changing experience of one of our faculty members who went through the ultimate role reversal from doctor to patient. Bryant Lynn, a beloved physician and educator at Stanford Medicine, received a shocking diagnosis in May of 2024 after he went to the doctor's office for what he thought were bad seasonal allergies. The cough he'd been experiencing was actually the manifestation of stage four, never smoke or lung cancer. After his diagnosis, Brian, who's a clinical professor of medicine, he did something that not many patients would choose to do. He decided to openly share the course of his illness in the hopes that his story would leave an educational legacy. He developed a course for medical students and undergraduates that teaches about the complexities of cancer care from the perspective of both patient and physician. The course intimately follows his own experiences down to the very scans that diagnosed his illness. I spoke with Bryant about his personal and professional journey, his motivation to talk about his diagnosis and the lessons he's imparting to students around the emotional, medical and practical challenges of providing compassionate cancer care. Brian, welcome. It's a privilege to have this conversation with you today, and thank you so much for joining me.

Bryant Lin:

Great. Thanks for having me.

Maya Adam:

Brian. Your story is an incredible one, but before we dive into the journey that you've faced over the past few months, I wonder if you can tell us a bit about the path you followed to get to where you are in your career.

Bryant Lin:

Absolutely. Yeah. I've taken a somewhat atypical path, but at Stanford, it seems like everybody takes an atypical path into medicine. I studied engineering at MIT, electrical engineering, computer science, and got my master's, wasn't what I wanted to do. Worked for a brief year in management consulting. Did not find that very satisfying to say the least. Decided to go to medical school, went to Tufts. Went to Tufts, which at the time was called New England Medical Center for residency. And then after finishing when I was in my last year of residency, I reached out to Paul Wong, who was my mentor at Tufts, and he had gone to Stanford during my intern year, and I reached out to him and he let me know about the biodesign program. So I came to Stanford to be a postdoc cardiac research fellow with Paul and a biodesign fellow for a year.

And then I joined the faculty in 2006, sort of a part-time primary care faculty. And I gradually increased my time there. And so far I've been early on was working on a lot of medical devices, medical technology, working with companies and researching the space since I've been, this is my 20th year I think, at Stanford. And since I've been here, I started the Consultative Medicine Clinic, which was the diagnostic clinic also started to take students and residents on home visits before covid. Hopefully we'll restart them, but we had to stop because of covid. And then six years ago with Dr. Laha Polyon, I co-founded the Center for Asian Health Research and Education. And one of our priority areas was and is raising awareness and resources for education and research for lung cancer and never smokers, which differently impacts the Asian community. And of course, ironically, I have become the poster child for this effort as well.

Maya Adam:

Can you tell us a little bit more about the never smoker lung cancer and also about how it differentially impacts Asian populations?

Bryant Lin:

Absolutely. So lung cancer is the number one cause of cancer death in the US and the world up to 20% are actually never smokers or non-smokers, not active smokers. And Asians, especially Asian women, have a higher risk of getting never smoker lung cancer than other groups. And what happens is most Asians, so over 50% of Asians, they have a specific tumor mutation called an EGFR, epidermal growth factor receptor mutation. Whereas in non-Hispanic whites, it's actually less than 20% have that mutation. So yeah, it definitely impacts the Asian community in different ways, increased risk among Asian women. And again, this preponderance of people with this very specific mutation, we don't know why it happens. This is a common question I get asked, and I've asked myself, we don't know why this is different. This disease presents differently, is different in Asian populations. There have been lots of theories around cooking oil, cooking exposure, natural gas exposure, but it seems like family history is a strong predictor.

There was a large study in Taiwan, probably the largest of its kind, looking at using a low dose CT to screen for lung cancer and never smokers in both men and women 55 and up. And they looked at things like family history, cooking exposure, unvented cooking, kitchen, lack of ventilation, secondhand smoke exposure, and they found again, the strongest predictor among the groups was having a family history. So that is very interesting. So yeah, it's definitely an area of interest for our center for me personally, of course. And hopefully actually I've benefited from the advances in treatment for this EGFR mutation and hopefully we'll bring more attention and resources. So when I need a new treatment, it'll be available for me.

Maya Adam:

Brian, on that topic, can you tell us about the past few months?

Bryant Lin:

Yeah, absolutely. So this all started in the spring and I had a cough. It was a dry cough. I've had a long history of allergies and I thought it was just allergy related. I felt like a little tight, maybe a little wheezy. I thought, geez, maybe I'm developing allergy related asthma. And so I tried different inhalers, of course, eventually tried an antibiotic and then eventually got a chest X-ray and then a CT and get diagnosed via bronchoscopy. And yeah, it's been, of course, just a crazy ride. I was, before Memorial Day, I was supposed to get my first treatment, first IV chemotherapy. So because of a new study that was done last year called the Flower two trial, it showed that if you're on chemotherapy plus oral targeted therapy with a medication called osimertinib, the brand names Tagrisso, those patients do better. Stage four patients do better then if just doing the targeted therapy itself.

And so before that, a lot of stage four patients were just put on the targeted therapy if they had the EGFR mutation. So because I'm in otherwise good health, I started that. They gave me an IV antiemetic and unfortunately I had an anaphylactic reaction to that. So I had to go to the hospital. I had a syncopal episode, I had to go to the hospital. This was right before Memorial Day, and I had a lot of fluid in my lungs, pleural effusion, they drained 1.8 liters out from my right lung. And finally was discharged after a day, got excellent care, and I continued to get excellent care at Stanford. And after that, I was able to, the Tuesday after Memorial Day, was able to start my chemotherapy every three weeks. And so I got a combination chemotherapy at first, and now I'm on pemetrexed alone with a daily oral therapy.

And I've been very grateful because my cancer has responded. It's by no means gone, but it has responded. It has, some areas have shrunk. It's definitely not progressed. One thing that was frightening to me was I've been practicing medicine for basically 20 years, and I've never seen an MRI that said somebody had 50 areas of metastasis in the brain, 55 0, I had that. So that was quite shocking to see. I had 50, I mean expected. Well, lung cancer tends to be diagnosed late stage because people are very asymptomatic until the later stage. So I was expecting metastasis, which I had to the liver to different areas, to the skin even. But I wasn't expecting 50 areas of metastasis to the brain. And fortunately my second MRI showed that they had all gone except maybe for one. And then my third MRI showed there was no evidence of intracranial metastatic disease, but I still have two lung masses, two lung nodules, mass in my liver and areas of my bone that are impacted. But I feel, well, I'm very grateful. I feel well, I can I see patients. I never took a day off work actually since this all started. And the only concession I've made to cancer so far is to switch my patients to video instead of in person. So I don't get sick, unintentionally get sick. So I'm very grateful that I've been able to do everything I want to do so far.

Maya Adam:

Brian, in hearing you speak, I'm just reflecting on the choices we make. And I think sometimes in times of crisis, many people would choose to sort of retreat and focus on their own personal challenges and others will advance and sort of focus on catalyzing solutions for even bigger populations and bigger questions. And since learning about your diagnosis, you've decided to teach a whole course around cancer care and treatment, and you've given multiple interviews about your experience. I think you're writing a book. I'm curious about the motivation to share your journey.

Bryant Lin:

Yeah, I think there are many motivations. One is, of course, I tend to be the kind of person that tries to make lemonade from lemons, taking such a terrible thing and finding a benefit from it so other people can benefit. I find, at least in my mind, if I were a medical student, I would've loved to hear from somebody with one foot in both worlds. I still remember on my first day of medical school, this famous neurologist brought in a patient who he had not seen and did some, I don't even remember what it was, did some physical exam maneuvers and actually caused the patient a little bit of pain and then gave him this unusual diagnosis. So of course, all the students were like, oh, this is amazing. What an awesome doctor. But I still remember that case because the patient felt pain. So I was like, well, what about the patient?

What's the patient feeling? You're bringing this patient in front of all these people. It's such an odd situation there. And we're here to take care of patients. So I've always been a believer in learning about the patient journey and the patient stories. As I mentioned, I would as an educational exercise, bring students and residents to home visits. And so I think sharing that perspective as both a physician and a patient would be educational. And that also informed how we structured the class. 95% of your life as a patient is not appointments, getting tests, getting treatment. A lot of it's living your life, living your life with this disease, and of course, side effects from the treatment. So in addition to the regular things like screening, epidemiology, treatments, we also look at caregiving, spiritual care, nutrition, mental health access. So all of these things that are not traditionally directly medical mean nutrition is.

But there's a long history in medicine of not emphasizing nutritional education around nutrition as much as we should. So that's kind of what inspired me to teach the class. And so far the students have been very engaged and seem to have benefit from it. And again, I think I've learned as much as the students because the way the class is structured is we have a topic of the day, I share my part of the story or my reflections on that topic, and then we have an expert come in to talk about screening or diagnosis or treatment or nutrition or spiritual care. So I've learned a lot myself and hopefully the students find it beneficial.

Maya Adam:

And I heard that at one point your wife even joined one of the classes and shared her experience. Just getting back to what you said about how patients are living their lives outside of the clinic as well. Can you tell me a little bit about what that experience was like to have your wife take part in the class?

Bryant Lin:

Yeah, I mean, when we decided to have a caregiving session, I said, well, we have to have my wife, my primary caregiver at home. She takes great care of me. My rock provides both logistical caregiving but also emotional support for me. So yeah, it's lovely to have my wife in the class and to have her share this experience that I get to have, which is teaching students. So it was really wonderful to have that perspective. The other caregiver we invited is a father of a young woman. His daughter has severe cancer, and he also provided a great perspective because he actually didn't identify with the label caregiver. This is a medical label we put on people for research and we like to assign categories. And for him, he's like, I'm a father, I'm a father. I'm not a caregiver. I'm a father, and being a father is being a father. And there's all these things associated with him. Being a father and caring of course is part of that, but he really identified with being a father and not a caregiver. So hearing those varied perspectives and having the students think about how we categorize and label people was very important. But also sharing that lived experience of what it is to take care of a cancer patient was very important.

Maya Adam:

Has it shifted the dynamic? I mean, how has it changed that taking on that role of let's say caregiver, just because it's the label we started with, how has that shifted and how does it shift the day-to-day lives of people who have a relationship prior to that that doesn't involve the caregiver piece?

Bryant Lin:

Yeah, I think there's a huge variation, honestly. Yeah, I think there are some people who unfortunately at the beginning I was quite sick, but had some functional limitations and now I don't have too many functional limitations other than side effects from chemotherapy, nausea and fatigue and things like that. So I would say in our lives it hasn't really changed much other than she's taking care of me, which she did before, but it's a different context. It's making sure I eat well and I'm eating foods that would not at least increase my risk of getting cancer or getting worse cancer and being present and so forth. So I would say those parts don't change, but the context changes. I can definitely see, of course, as a physician, if you're taking care of somebody and my mother has advanced dementia and my father takes care of her, that does change the dynamic quite a lot.

A lot of functional changes, functional help, you're helping them with their activities of daily living, so that can change the dynamic quite significantly. That hasn't been the case for me because of my functional status has been quite good. People will look at me and I can tell you, having gone med school 20 plus years ago, if you told me that I look like I'm a stage four cancer patient, I'd say no way. At that time, especially stage four cancer patients were quite sick. And that has really drastically changed over the last 20 plus years. I'm grateful that I am very functional and have great relationships and great support, and I really recognize how privileged I am to be. We talked about healthcare access in our class, and one of the things I brought up that the students hadn't thought of when I asked them, Hey, why do you think I was able to get good care? Of course, they're like, well, you're a doctor, people, blah, blah, blah. You have insurance. And I pointed out, and these are great, they covered most of the reasons, but I said, Hey, I speak English, I speak English, and people who don't speak English well or speak English at all have challenges and barriers to care. So I recognize that I'm in a quite privileged group where even though it's challenging, I have the support and resources to get excellent care and so that my caregivers can really hopefully not be overly burdened with my care.

Maya Adam:

And Brian, the second week I think of your class focused on how to have difficult conversations as a physician, I wonder what your actual experience of that has been and how you communicate that to how can you teach those skills to your students?

Bryant Lin:

This is something that does honestly take some experience, and everyone develops their own style and their own process for having a difficult conversation with a patient. And there's a balance to be had. There's a balance between being straightforward because it's hard. People hear what they want to hear, and you're getting with cancer, such a complicated diagnosis, so many things involved, but you want to be also, and this is something maybe has changed since getting my cancer diagnosis, you also want to be hopeful, right? It's very easy, especially during our training, to relay things like survival curves and statistics and prognosis. And as speaking as a cancer patient, it doesn't really help anybody to really think about that. Geez, I have a 10% likelihood of surviving the next five years. Otherwise, you would just give up. Just make yourself miserable. So maintaining that hope is very important.

I think for the patient. We had a guest yesterday, so the topic yesterday was on mental health and cancer stories. And early on I spoke to Dr. Davies Wong, who's a pulmonologist out of Sharp, and he was introduced to me by a medical school classmate who's also a pulmonologist, and he said, as a day-to-Day, ICU doctor, he said, yeah, I used to be, he deals with life and death literally every day. He used to be a little bit more blunt and straightforward about prognosis, but given his experience as someone who, as a lung cancer survivor, he really has also been more cognizant of how hope plays into the picture. And so there's that balance there, and it's tricky. I do think this is something that we give advice and guidance and we have an interview guide for students, but some of this has to come through experience. And as a primary care provider, in a way, it's a little easier for me because most of my patients I've known for years, if not more than a decade. So that does change the dynamic as well. Compared to somebody you just met,

Maya Adam:

Brian, you mentioned a few minutes ago spirituality and the importance of spirituality. Can you tell us how that plays a part and why it's so important for a medical team to incorporate a patient's spiritual needs?

Bryant Lin:

Absolutely wouldn't. I'm not a religious person. At most, I would say I would call myself agnostic, and I never thought of myself as a spiritual person. But the reason we added that session in our class was I was overwhelmed by how many people reached out to me and said they would pray for me, they would pray with me, they would bring their pastor, they would light a candle for me, people from different religions. I had people send me Hindu chants. I had a friend send me a tro, which is a little object to focus your meditation around. And had people who practiced Buddhism talk about how they would also practice their religion and chant and observe Buddhist practices for me, and I found that very comforting. I found that really deeply moved me, that people would bring their own spiritual practices and spiritual care for the support of me and day to day, the questions that come up when you have stage four cancer, which is not considered curable, is really, they're really metaphysical questions. They're really spiritual questions. There's a practical component of, well, day, I ask myself, how do I want to spend today? Is this a good use of my time? Should I spend my time seeing patients and talking to media, or should I be doing something different? And so I reassess that every day. And fortunately, the answer generally has been the same is I enjoy what I'm doing and I find benefit from it personally, and hopefully I'm benefiting other people, so I'll continue doing this.

So I think that part really has shown to me how important that spiritual side is. It's not all about facts and numbers and treatment. And the great advice that also from Dr. Wong, he said, well, don't look at the survival curves, and you just have to think, geez, maybe I can live long enough until the next treatment comes out. But day to day, you still think about what do I value? What do I hope for? What are my hopes and dreams? I don't plan out five years anymore, but I still think about those issues which are deeply rooted in spiritual care and spiritual belief. I was kind of interested about how spiritual care is not brought up in medicine that much at all. We have chaplains and so forth. So one thing I found out was chaplaincy. Chaplaincy services are generally not covered by insurance. So hospitals are paying for these chaplains themselves or relying on volunteer chaplains. I was also interested, so I did a search on PubMed. PubMed is a big index for medical articles, and I typed in chemotherapy and there are 400,000 articles, right, as expected. And then I typed in not even spiritual care, just spiritual, and there are 8,000 articles. So it's interesting how we don't value the spiritual, at least on a research basis, even though I would say, I would argue that a lot of people would say that spiritual care is at least as important as the chemotherapy they're getting.

Maya Adam:

How much evidence is there, if any, for the role of, for example, hope in cancer care or spirituality? Do we have any science around that? Yeah,

Bryant Lin:

I think there is some science between positive thinking and better outcomes. I think. So these are a lot of the unknowns, but I don't think it's studied as well enough as I would honestly. First of all, I mean as a researcher, it's difficult to study. How do you assess this? People are self-reporting how they feel or their optimism and so forth, and these are self-reported subjective assessments. And then what outcome are you looking for? All outcomes are interesting, but are you looking for outcomes like mortality, which are hard outcomes to move? Are you looking for outcomes like morbidity, hospitalizations, or quality of life? Right? What's important? What are we putting priorities on? So one, yes, I think there is some evidence that positive thinking is helpful. Two, it's not magic by any means, but three that may reflect your engagement of other things as well may be a lot of confounders about if you're positive, maybe you're more likely to take your medicine.

Maybe you're likely more likely to take care of yourself. So there may be other factors which are hard to quantify and to capture. So I definitely think there should be research in this. I think there should be also mechanistic research. How does it change your brain? I'm sure there's been functional MRI studies on people in prayer and other areas, but I'm also very confident without having done an in-depth literature review that we probably don't have that much research in the area. It's not typically the area where you get a lot of NIH grants or other funding, which really drives our research ecosystem.

Maya Adam:

Brent, for any listeners who are basically hearing this story and sort of seeing themselves in your experience, is there anything you'd want to specifically say to them? Any advice you'd give to them?

Bryant Lin:

Yeah, I think storytelling is powerful and we humans have a great ability to generalize from other people's stories and find that connection, even though they may have a different type of cancer. I'm not a big believer in advice, but I do believe this is something where this is a time, if you get a cancer diagnosis, it's a great time to really reflect, to get help to gather your village around you. It's so complicated to get cancer care now and to find your support both on a physical basis. People are amazing and they'll offer to cook food for you, and you'll have a freezer full of food that people will give you, but also on an emotional, spiritual basis, getting that support. I was just on a panel about doctors who've faced cancer diagnoses either currently or in the past, and even people who have been treated and are in remission, some of them struggle with reintegrating their lives back.

Some of them struggle with guilt. So I can say that I think a broader support system is, I mean, I can't imagine that will not be helpful. I think share your story if you find it helpful. Some people are, I get that question a lot. Why are you sharing your story? Because there's a little bit of a stigma in a way I've seen behind sharing your story or diagnoses of any illness. But in certain people, it may be helpful to share their story and your story may help other people. So I don't know if this is great advice, but these are kind of my reflections on your question.

Maya Adam:

I'm thinking as I'm listening to you speak that sometimes in sharing your own vulnerability, you can showcase the most unimaginable strength.

Bryant Lin:

Yeah, I suspect so. I think the benefit of sharing is, of course, the multifold benefits of having to think about it, having to synthesize your thoughts, put it into a recording or on paper, communicating what you're going through, that generally has been found to be helpful in areas such as narrative medicine for both physicians and for patients. Yeah, I do think that that could be a way that they're getting control. So speaking of strength, that could be a way, and this was talked about in our panel today. One of the guests came to give grand rounds, and that is a way that you can regain control of your own story and cancer. You're so subject to other forces that you have no control over, but telling your story could be one way you regain at least a small part of that control.

Maya Adam:

I am so grateful to you for joining us today, and thank you for everything that you're doing for the legacy that you're leaving and you're an inspiration. Thank you so much.

Bryant Lin:

Great. Thanks for having me.

Maya Adam:

Thank you for listening to Stanford Medicine's Health Compass podcast. If you like what you heard today and want to keep up with Health Compass, you can subscribe on Apple Podcasts, Spotify, the Stanford Medicine YouTube channel, or wherever you like to listen.